Treatment–resistant panic disorder: a systematic review

[Treatment resistance in anxiety disorders-Definition and treatment options]

Treatment resistance in anxiety disorders represents a clinical challenge, contributes to the chronicity of the diseases as well as sequential comorbidities, and is associated with a significant individual and socioeconomic burden. This narrative review presents the operational definition of treatment resistance in anxiety disorders according to international consensus criteria (< 50% reduction in the Hamilton Anxiety Scale, HAM‑A, score or < 50% reduction in the Beck Anxiety Inventory, BAI, score or a clinical global impression-improvement, CGI‑I, score > 2). At least two unsuccessful guideline-based treatment attempts with pharmacological monotherapy or at least one unsuccessful treatment attempt with adequately delivered cognitive behavioral therapy are required. Pharmacotherapeutically, after excluding pseudo-resistance, switching the medication within one class or to another class and augmentation strategies with other antidepressants (mirtazapine, agomelatine), antipsychotics (quetiapine) or anticonvulsants (valproate) are recommended. Psychotherapeutically, third-wave therapies, psychodynamic therapy, systemic therapy and physical exercise can be considered for therapy resistance. In cases of no response to psychotherapy or pharmacotherapy, the respective other form of therapy or a combination of both should be offered. Compounds targeting the glutamatergic and endocannabinoid systems as well as neuropeptides are being tested as potential innovative pharmaceuticals for treatment-resistant anxiety disorders. There is an urgent need for further research to identify predictive markers and mechanisms as well as to develop innovative pharmacological and psychotherapeutic interventions for treatment-resistant anxiety disorders.

Antipsychotic agents in anxiety disorders: An umbrella review

BACKGROUND

Although not approved for the treatment of anxiety disorders (except trifluoperazine) there is ongoing off-label, unapproved use of first-generation antipsychotics (FGAs) and second-generation antipsychotics (SGAs) for anxiety disorders. There have been systematic reviews and meta-analyses on the use of antipsychotics in anxiety disorders, most of which focused on SGAs.

OBJECTIVE

The specific aims of this umbrella review are to: (1) Evaluate the evidence of efficacy of FGAs and SGAs in anxiety disorders as an adjunctive treatment to traditional antidepressant treatments and other nonantipsychotic medications; (2) Compare monotherapy with antipsychotics to first-line treatments for anxiety disorders in terms of effectiveness, risks, and side effects. The review protocol is registered on PROSPERO (CRD42021237436).

METHODS

An initial search was undertaken to identify systematic reviews and meta-analyses from inception until 2020, with an updated search completed August 2021 and January 2023. The searches were conducted in PubMed, MEDLINE (Ovid), EMBASE (Ovid), APA PsycInfo (Ovid), CINAHL Complete (EBSCOhost), and the Cochrane Library through hand searches of references of included articles. Review quality was measured using the AMSTAR-2 (A MeaSurement Tool to Assess Systematic Reviews) scale.

RESULTS

The original and updated searches yielded 1796 and 3744 articles respectively, of which 45 were eligible. After final review, 25 systematic reviews and meta-analyses were included in the analysis. Most of the systematic reviews and meta-analyses were deemed low-quality through AMSTAR-2 with only one review being deemed high-quality. In evaluating the monotherapies with antipsychotics compared with first-line treatments for anxiety disorder there was insufficient evidence due to flawed study designs (such as problems with randomization) and small sample sizes within studies. There was limited evidence suggesting efficacy of antipsychotic agents in anxiety disorders other than quetiapine in generalized anxiety disorder (GAD).

CONCLUSIONS

This umbrella review indicates a lack of high-quality studies of antipsychotics in anxiety disorders outside of the use of quetiapine in GAD. Although potentially effective for anxiety disorders, FGAs and SGAs may have risks and side effects that outweigh their efficacy, although there were limited data. Further long-term and larger-scale studies of antipsychotics in anxiety disorders are needed.

The definition of treatment resistance in anxiety disorders: a Delphi method-based consensus guideline

Anxiety disorders are very prevalent and often persistent mental disorders, with a considerable rate of treatment resistance which requires regulatory clinical trials of innovative therapeutic interventions. However, an explicit definition of treatment-resistant anxiety disorders (TR-AD) informing such trials is currently lacking. We used a Delphi method-based consensus approach to provide internationally agreed, consistent and clinically useful operational criteria for TR-AD in adults. Following a summary of the current state of knowledge based on international guidelines and an available systematic review, a survey of free-text responses to a 29-item questionnaire on relevant aspects of TR-AD, and an online consensus meeting, a panel of 36 multidisciplinary international experts and stakeholders voted anonymously on written statements in three survey rounds. Consensus was defined as ≥75% of the panel agreeing with a statement. The panel agreed on a set of 14 recommendations for the definition of TR-AD, providing detailed operational criteria for resistance to pharmacological and/or psychotherapeutic treatment, as well as a potential staging model. The panel also evaluated further aspects regarding epidemiological subgroups, comorbidities and biographical factors, the terminology of TR-AD vs. "difficult-to-treat" anxiety disorders, preferences and attitudes of persons with these disorders, and future research directions. This Delphi method-based consensus on operational criteria for TR-AD is expected to serve as a systematic, consistent and practical clinical guideline to aid in designing future mechanistic studies and facilitate clinical trials for regulatory purposes. This effort could ultimately lead to the development of more effective evidence-based stepped-care treatment algorithms for patients with anxiety disorders.

A preliminary examination of unified protocol for transdiagnostic treatment of emotional disorders in patients with panic disorder: a single-case experimental design in Iran

BACKGROUND AND OBJECTIVES

The majority of patients suffering from anxiety disorders in low- and middle-income countries do not receive evidence-based treatments. The Unified Protocol (UP) for the Transdiagnostic Treatment of Emotional Disorders is an evidence-based cognitive-behavioral intervention designed to treat the range of emotional disorders.

DESIGN AND METHODS

Using a single-case experimental design five patients with panic disorder were assigned to a 3-week baselines assessment phase followed by eight sessions of UP treatment and 4-week follow-up phases. Multiple outcome measures of panic severity, anxiety sensitivity, affectivity, and overall anxiety severity and impairment were administered weekly during the baseline, intervention, and follow-up phases.

RESULTS

At post treatment, all participants showed significant reductions in outcome measures, with changes functionally related to treatment and most improvements maintained at 4-week follow-up.

CONCLUSION

Findings provide preliminary cross-cultural support for UP and add to the growing body of literature showing UP can be useful for patients with anxiety disorders in low- and middle-income countries with non-Western cultures.

Panic disorder in general medical practice- A narrative review

The under-or misdiagnosis, and symptomatic treatment of the panic disorder (PD), despite high prevalent medical illness, is common among non-psychiatric physicians. The non-psychiatrist physician’s role is vital in the care of PD as most patients initially approach general medical settings for medical help, including primary care. However, a significant proportion is undiagnosed and undergoes either unnecessary investigation, misdiagnosed, or mismanaged even among post-Coronary Artery Bypass Grafting patients, which profoundly affects the patients functioning and quality of life. This article aims to provide overviews of relevant epidemiological aspects, presenting features across medical specialties with respective diagnostic dilemmas, assessment, and management of the PD in their general medical settings, including emergency visits. Apart from psychiatrists, this will also assist non-psychiatrist physicians across all medical specialties, including general practitioners, to understand, identify, and provide the first line evidence-based pharmacotherapy and address the unmet need of patients with PD in their day-to-day busy clinical practice. This paper also provides a referral guide for non-psychiatrist physicians to refer to psychiatrists for further management after their first-line management.

A fog assisted intelligent framework based on cyber physical system for safe evacuation in panic situations

In the current scenario of the COVID-19 pandemic and worldwide health emergency, one of the major challenges is to identify and predict the panic health of persons. The management of panic health and on-time evacuation prevents COVID-19 infection incidences in educational institutions and public places. Therefore, a system is required to predict the infection and suggests a safe evacuation path to people that control panic scenarios with mortality. In this paper, a fog-assisted cyber physical system is introduced to control panic attacks and COVID-19 infection risk in public places. The proposed model uses the concept of physical and cyber space. The physical space helps in real time data collection and transmission of the alert generation to the stakeholders. Cyberspace consists of two spaces, fog space, and cloud-space. The fog-space facilitates panic health and COVID-19 symptoms determination with alert generation for risk-affected areas. Cloud space monitors and predicts the person's panic health and symptoms using the SARIMA model. Furthermore, it also identifies risk-prone regions in the affected place using Geographical Population Analysis. The performance evaluation acknowledges the efficiency related to panic health determination and prediction based on the SARIMA with risks mapping accuracy. The proposed system provides an efficient on time evacuation with priority from risk-affected places that protect people from attacks due to panic and infection caused by COVID-19.

Unconscious processing of subliminal stimuli in panic disorder: A systematic review and meta-analysis

Attentional biases to threat exist in panic disorder (PD), probably related to altered subliminal processing. We systematically reviewed studies investigating subliminal processing in PD. Studies were retrieved from MEDLINE and Scopus®. We meta-analytically compared PD (n = 167) and healthy controls (HC, n = 165) for processing of masked panic-related and neutral words. We also compared subliminal and supraliminal presentations of panic-related words relative to neutral words within PD subjects and HC. We found a significantly enhanced Stroop interference to masked panic-related words in PD vs HC (Hedges' g = 0.60, p = 0.03; Q = 14.83, I² = 66.3 %, p = 0.01). While both PD subjects and HC tended to be slower to respond to supraliminal threat words than to neutral words, PD subjects only showed a marginally significant slower response to subliminal panic-related words vs neutral words. Findings remain inconclusive regarding comparison to other mental disorders, neural correlates, and the effect of psychotherapy. Even if possibly flawed by methodological weaknesses, our findings support the existence of a sensitivity to subliminal threat cues in PD, which could be targeted to improve treatment.

Fog-assisted Energy Efficient Cyber Physical System for Panic-based Evacuation during Disasters

Disasters around the world have adversely affected every aspect of life and panic-health of stranded persons is one such category. An effective and on-time evacuation from disaster-affected areas can avoid any panic-related health problems of the stranded persons. Although the nature of disasters differ in terms of how they occur, the evacuation of stranded persons faces approximately same set of issues related to the communication, time-sensitive computation and energy efficiency of the devices operated in the disaster-affected areas. In this paper, a cyber physical system (CPS) is proposed that takes into account various challenges of the disaster evacuation, so an efficient on-time and orderly evacuation of stranded panicked persons could be realized. The system employs fog-assisted mobile and UAV devices for time-sensitive computation services, data relaying and energy-aware computation. The system uses a fog-assisted two-factor energy-aware computation approach using data reduction, which enables the energy-efficient data reception and transmission (DRecTrans) operations at the fog nodes and compensates to extend the period for other functionalities. The data reduction at fog devices employs Novel Events Identification (NEI) and Principal Component Analysis (PCA) for detecting consecutive duplicate traffic and data summarization of high dimensional data, respectively. The proposed system operates in two spaces: physical and cyber. Physical space facilitates real-world data acquisition and information sharing with the concerned stakeholders (stranded persons, evacuation teams and medical professionals). The cyber space houses various data-analytics layers and comprises of two subspaces: fog and cloud. The fog space helps in providing real-time panic-health diagnostic and alert services and enables the optimized energy consumption of devices operate in disaster-affected areas, whereas the cloud space facilitates the monitoring and prediction of panic severity of the stranded persons, using a conditional probabilistic model and seasonal auto regression integrated moving average (SARIMA), respectively. Cloud space also facilitates the disaster mapping for converging the evacuation map to the actual situation of the disaster-affected area, and geographical population analysis (GPA) for the identification of the panic severity-based critical regions. The performance evaluation of the proposed CPS acknowledges its Logistic Regression-based panic-well being determination and real-time alert generation efficiency. The simulated implementation of NEI and PCA depicts the fog-assisted energy efficiency of the DRecTrans operations of the fog nodes. The performance evaluation of the proposed CPS also acknowledges the prediction efficiency of the SARIMA and disaster mapping accuracy through GPA. The proposed system also discusses a case study related to the pandemic disaster of coronavirus disease 2019 (COVID-19), where the system can help in panic-based selective testing of the persons, and preventing panic due to distressing period of COVID-19 outbreak.

In vivo investigation on bio-markers of perimenopausal panic disorder and catgut embedding acupoints mechanism

BACKGROUND

Panic disorder (PD), defined by repeated and unexpected panic attacks, severely affects patients' living quality and social function. Perimenopausal women are high-risk group of PD and suffer greatly from it. Modern medicine therapies for this disorder have many side reactions and poor effects, so nonpharmacological modality is an urgent need. Although acupoint catgut embedding is widely used in clinical practice, there is no persuasive evidence of its effect for perimenopausal PD. The aim of this study is to investigate the effectiveness and safety of acupoint catgut embedding for perimenopausal PD and to elucidate the correlations among brain neural activation, bio-markers (amino acids) and clinical outcomes with radiographic evidence, thus to explore its neural mechanism.

METHODS

The parallel designed, exploratory randomized controlled trial will include 70 outpatients with perimenopausal PD recruited from two hospitals of Chinese Medicine. These subjects will be randomly allocated to an intervention group (Group Embedding) and a control group (Group Medication) in a 1:1 ratio. The subjects in the intervention group will receive acupoint catgut embedding treatment two weeks a time in the following predefined acupuncture points: Shenshu (BL23), Sanyinjiao (SP6), Guanyuan (RN4), Ganshu (BL18), Zusanli (ST36) and Pishu (BL20). The included women of the control group will take 0.4 mg Alprazolam tablet orally, 1 tablet a time, 3 times a day. There is a study period of 3 months and a follow-up period of 1 month for each group. The primary outcomes will be the following therapeutic indexes: the frequency of panic attack, Panic Disorder Severity Score (PDSS), and Panic-associated Symptoms Score (PASS) during the observation period and follow-up period. The changes in Hamilton Anxiety Scale (HAMA) Score and Symptom Checklist 90 (SCL-90) Score will also be compared between these two groups. Additionally, functional magnetic resonance imaging (fMRI) and proton magnetic resonance spectroscopy (1H-MRS) scans will be done before and after the observation period to show cranial neuroimaging changes.

DISCUSSION

We present a study design and rationale to explore the effectiveness and neural mechanism of acupoint catgut embedding for perimenopausal PD. There are still several factors restrict our research such as no unified standard of diagnostic criteria and curative effect evaluation.

TRIAL REGISTRATION

Chinese Clinical Trial Registry, ChiCTR-INR-16009724, registered in November 2016.

Changes in mean platelet volume and hematologic indices in patients with panic disorder due to oxidative stress

OBJECTIVE

Cardiovascular disorders are common in patients with panic disorder (PD), usually mediated by platelets. The present study was conducted to evaluate oxidative stress conditions and complete analysis of blood cells in patients with PD.

SETTING AND SAMPLE POPULATION

Sixty healthy individuals and 60 patients were included in the study. Whole blood and serum samples were obtained from patients and controls.

MATERIALS & METHOD

Hematological studies, including blood cells count, hemoglobin, and hematocrit, were carried out on whole blood samples. In addition, oxidative stress indices including total antioxidant capacity, free oxygen species, and malondialdehyde concentration were measured in serum samples.

RESULTS

Results showed that patients with PD had a significant increase in mean platelet volume index (MPV), platelet distribution width (PDW), red blood cell distribution width (RDW), and mean corpuscular hemoglobin concentration (MCHC) compared with healthy subjects (p < .05). Also, oxidative stress indices were significantly elevated in patients with PD compared with control group (p < .05).

CONCLUSION

Elevated MPV is a hematologic indicator for patients with PD. This disorder may be caused by impaired serotonin metabolism, resulting in increased oxidative stress, as well as in platelet serotonin transporters. Regarding elevated oxidative stress, the risk of cardiovascular complications is high in patients with PD.

Mean Platelet Volume and Platelet Distribution Width Level in Patients with Panic Disorder

Background:

Changes in platelet indices have been reported in patients with panic disorder (PD). However, previous study findings are contradictory and inconclusive. The aim of this study was to evaluate and compare the platelet indices in patients with PD.

Materials and Methods:

Patients with PD (n = 123) and healthy controls (n = 133) were enrolled in this case control study. The platelet indices (mean platelet volume [MPV] and platelet distribution width [PDW]) along with red blood cell (RBC) indices (RBC count and red cell distribution width [RDW]) were compared between the two groups using the unpaired t-test.

Results:

Patients with PD had lower MPV (7.53 ± 0.93 fL vs. 8.91 ± 1.24 fL, P < 0.0001), higher PDW (16.96 ± 0.85 fL vs. 14.71 ± 2.07 fL, P < 0.0001), and higher platelet count (274.2 ± 80.66 × 10⁹ L⁻¹ vs. 243.1 ± 93.89 × 10⁹ L⁻¹, P < 0.005) than the healthy controls. Furthermore, there were significant differences between patients with PD and healthy controls in terms of their RBC count (4.32 ± 0.56 × 10¹² L⁻¹ vs. 4.08 ± 0.80 × 10¹² L⁻¹, P = 0.007) and RDW (16.48 ± 2.26 fL vs. 15.01 ± 2.25 fL, P < 0.0001).

Conclusion:

Patients with PD have increased PDW and RDW. The platelet and RBC indices may prove to be useful etiological and prognostic markers in patients with PD.

Pharmacological and Neuromodulatory Treatments for Panic Disorder: Clinical Trials from 2010 to 2018

OBJECTIVE

Treatment for panic disorder (PD) have evolved, although there is still a strong unmet need for more effective and tolerable options. The present study summarizes and discusses recent evidence regarding the pharmacological and neuromodulatory treatment of PD.

METHODS

MEDLINE, Cochrane Library, PsycINFO and Thomson Reuters's Web of Science were searched for clinical trials published between 2010 and 2018. We included all prospective experimental studies including randomized controlled trials (RCT) and other clinical trials with more than 10 patients.

RESULTS

Only 11 articles met the inclusion criteria, including 4 RCT, 3 open clinical trials and 5 comparative clinical trials. RCT demonstrated efficacy of transcranial magnetic stimulation (TMS) in only one of two trials. Neither pindolol nor d-fenfluramine were effective in blocking flumazenil-induced panic attacks. Augmentation with quetiapine was not superior to placebo. Open trials indicated that escitalopram, vortioxetine and TMS may be effective. Comparative trials did not demonstrate superiority from any drug, but confirmed tranylcypromine, paroxetine, clonazepam and alprazolam as effective options.

CONCLUSION

The current study confirmed the efficacy of tranylcypromine, paroxetine, clonazepam, alprazolam and escitalopram. Vortioxetine and TMS, with duration of 4 or more weeks, also seems to be effective. Quetiapine, pindolol and d-fenfluramine were not considered effective compounds.

Empirical evidence of the effect of personality pathology on the outcome of panic disorder

BACKGROUND

Treatment resistant disorders are a significant clinical problem. Impediments to good outcome need to be identified and addressed. Personality pathology has been hypothesized to be one such factor in panic disorder. There is no consensus as to the effects of personality pathology on the outcome of panic disorder. This study examined empirical evidence. The hypothesis was that personality pathology would cause poorer outcome of panic disorder.

METHODS

A literature search was conducted that winnowed 2627 articles down to 27 based on 1) longitudinal design; 2) validated measures of personality; 3) validated outcome measures; and 4) the presence of effect size or data to calculate effect size. All effect sizes were translated into odds ratios (ORs) for ease of comparison.

RESULTS

An overall median OR of 2.7 was found, indicating personality pathology negatively affected outcome. This finding persisted even when adjusted for baseline severity of illness. The effects were found for both clinical outcomes (OR = 2.7) and for social adjustment (OR = 2.9). There was a tendency for more dropouts in the personality pathology group. More highly structured drug therapy regimens and highly structured psychotherapy seemed to partially mitigate this outcome.

CONCLUSION

The negative effect of personality pathology was confirmed in well-designed longitudinal studies. This was not related to initial clinical severity. Clinical implications are that patients with personality pathology require the therapist to stick more closely to treatment protocols and to mitigate the tendency of these patients to drop out of treatment.

Are there advances in pharmacotherapy for panic disorder? A systematic review of the past five years

INTRODUCTION

Several effective medications are available for treating panic disorder (PD). However, outcomes are unsatisfactory in a number of patients, suggesting the usefulness of expanding the array of antipanic drugs and improving the quality of response to current recommended treatments.

AREAS COVERED

The authors have performed an updated systematic review of pharmacological studies (phase III onwards) to examine whether advances have been made in the last five years. Only four studies were included. D-cycloserine no longer seemed promising as a cognitive-behavioral therapy (CBT) enhancer. Some preliminary findings concerning the optimization of recommended medications deserved consideration, including: the possibility that SSRIs are more effective than CBT alone in treating panic attacks, combined therapy is preferable when agoraphobia is present, and clonazepam is more potent than paroxetine in decreasing panic relapse.

EXPERT OPINION

Given the lack of novel treatments, expanding a personalized approach to the existing medications seems to be the most feasible strategy to improve pharmacotherapy outcomes regarding PD. Recent technological progress, including wearable devices collecting real-time data, 'big data' platforms, and application of machine learning techniques might help make outcome prediction more reliable. Further research on previously promising novel treatments is also recommended.

Effect of high-frequency repetitive transcranial magnetic stimulation (rTMS) in patients with comorbid panic disorder and major depression

OBJECTIVE

To explore the role of dorsolateral prefrontal cortex (DLPFC) stimulation in the treatment of panic disorder with comorbid depression.

METHODS

The present study reports findings from retrospective analysis of 13 treatment-resistant patients diagnosed with comorbid panic disorder and depression, given 20 sessions of high-frequency transcranial magnetic stimulation (rTMS) over left-DLPFC over a period of 1 month.

RESULTS

There was a significant reduction in both the panic and depressive symptom severity, assessed by applying Panic Disorder Severity Scale (PDSS) and Hamilton Depression Rating Scale (HDRS) at baseline and after 20 sessions of rTMS. There was a 38% and 40% reduction of PDSS and HDRS scores, respectively, in the sample. The changes in PDSS and HDRS scores were not significantly correlated (ρ = -0.103, p = 0.737).

CONCLUSIONS

High-frequency rTMS delivered at left-DLPFC may have a potential role in treatment of comorbid panic disorder and depression. Future studies done on a larger sample in a controlled environment are required to establish its role.

An open-label, flexible dose adaptive study evaluating the efficacy of vortioxetine in subjects with panic disorder

BACKGROUND

Despite the current treatments available for panic disorder (PD), as many as one-third of patients have persistent and treatment-resistant panic attacks. Vortioxetine is an approved medicine for major depressive disorder and has been shown to have anxiolytic properties. The purpose of this study was to evaluate its efficacy and safety in an adult population with a diagnosis of PD.

METHODS

The study design was open label with flexible dose strategies (5, 10, or 20 mg) with a treatment period of 10 weeks. 27 male and female subjects aged between 18 and 60 years, who met DSM-IV criteria for PD with or without agoraphobia, or who had a Panic Disorder Severity Scale (PDSS) score > 8 at baseline were enrolled. Statistical significance was established by the Student's T test.

RESULTS

A statistically significant decrease in the occurrence of panic attacks was measured with the PDSS with vortioxetine. In addition, a moderate improvement in the quality of life and no significant side effects were observed using the Quality-of-Life Scale and Monitoring of Side Effects Scale, respectively.

CONCLUSIONS

These results provide some support for the use of vortioxetine in the management of panic disorder.Trial registration ClinicalTrials.gov ID#: NCT02395510. Registered March 23, 2015, https://clinicaltrials.gov/ct2/show/NCT02395510.

The Place of Antipsychotics in the Therapy of Anxiety Disorders and Obsessive-Compulsive Disorders

PURPOSE OF REVIEW

The purpose of this review was to assess and present the findings up to this date on the efficacy of antipsychotics in the treatment of generalized anxiety disorders (GAD), social anxiety disorders (SAD), panic disorders (PD), and obsessive-compulsive disorders (OCD), mostly based on published randomized controlled trials (RCTs) or on open-label studies when RCT were lacking.

RECENT FINDINGS

Quetiapine could be recommended in patients with GAD. The efficacy of aripiprazole in two open-label studies on patients with antidepressant-refractory GAD should be assessed in RCTs. Despite preliminary positive results in open studies, there are currently no strong evidence for the effectiveness of antipsychotics in refractory SAD and in refractory PD. Conversely, risperidone and aripiprazole can be used for the treatment of refractory OCD as augmentation agents to antidepressants. Contrary to SAD and PD, this review found evidence for the use of second-generation antipsychotics in GAD and OCD. Otherwise, first-generation antipsychotics cannot be recommended in anxiety disorders and OCD.

Management of Treatment-Resistant Panic Disorder

PURPOSE OF REVIEW

Purpose of Review Management of treatment-resistant (TR) panic disorder (PD) is an unresolved issue. In this paper, we provide a brief summary of previous findings, an updated (2015-2017) systematic review of pharmacological/non-pharmacological studies, and our personal perspective on this topic.

RECENT FINDINGS

Recent Findings We found a very limited number of recent findings. Quetiapine extended-release augmentation has not been found to be beneficial, in comparison to placebo, in non-responders to previously recommended pharmacotherapy. In non-responders to cognitive behavioral therapy (CBT), switching to paroxetine/citalopram has been found to be more effective than continuing CBT. Acceptance and commitment therapy (ACT) has shown some improvement in patients' resistance to previous psychological/pharmacological interventions compared with a waiting-list condition.

SUMMARY

Summary Previous and recent findings regarding the treatment of TR PD suffer from several methodological limitations. Available studies provide insufficient evidence to support the use of medications alternative to the recommended medications; the efficacy of ACT needs confirmation with more rigorous methodology. Prolonged pharmacotherapy may produce significant improvement in patients with unsatisfactory response to short-term pharmacotherapy, while switching to pharmacotherapy may help non-responders to CBT. We discuss our personal perspective on the definition of "treatment resistance" as it relates to PD and provide personalized intervention strategies to increase favorable clinical outcomes based on our clinical expertise and review of experimental studies on the pathophysiology of PD.

Improving outcomes for patients with medication-resistant anxiety: effects of collaborative care with cognitive behavioral therapy

BACKGROUND

Many patients with anxiety disorders remain symptomatic after receiving evidence-based treatment, yet research on treatment-resistant anxiety is limited. We evaluated effects of cognitive behavioral therapy (CBT) on outcomes of patients with medication-resistant anxiety disorders using data from the Coordinated Anxiety Learning and Management (CALM) trial.

METHODS

Primary care patients who met study entry criteria (including DSM-IV diagnosis of generalized anxiety disorder, panic disorder, posttraumatic stress disorder, or social anxiety disorder) despite ongoing pharmacotherapy of appropriate type, dose, and duration were classified as medication resistant (n = 227). Logistic regression was used to estimate effects of CALM's CBT program (CALM-CBT; chosen by 104 of 117 medication-resistant patients randomized to CALM) versus usual care (UC; n = 110) on response [≥ 50% reduction of 12-item Brief Symptom Inventory (BSI-12) anxiety and somatic symptom score] and remission (BSI-12 < 6) at 6, 12, and 18 months. Within-group analyses examined outcomes by treatment choice (CBT vs. CBT plus medication management) and CBT dose.

RESULTS

Approximately 58% of medication-resistant CALM-CBT patients responded and 46% remitted during the study. Relative to UC, CALM-CBT was associated with greater response at 6 months (AOR = 3.78, 95% CI 2.02-7.07) and 12 months (AOR = 2.49, 95% CI 1.36-4.58) and remission at 6, 12, and 18 months (AORs = 2.44 to 3.18). Patients in CBT plus medication management fared no better than those in CBT only. Some evidence suggested higher CBT dose produced better outcomes.

CONCLUSIONS

CBT can improve outcomes for patients whose anxiety symptoms are resistant to standard pharmacotherapy.

Is There Room for Second-Generation Antipsychotics in the Pharmacotherapy of Panic Disorder? A Systematic Review Based on PRISMA Guidelines

A role for second-generation antipsychotics (SGAs) in the treatment of panic disorders (PD) has been proposed, but the actual usefulness of SGAs in this disorder is unclear. According to the PRISMA guidelines, we undertook an updated systematic review of all of the studies that have examined, in randomized controlled trials, the efficacy and tolerability of SGAs (as either monotherapy or augmentation) in the treatment of PD, with or without other comorbid psychiatric disorders. Studies until 31 December 2015 were identified through PubMed, PsycINFO, Embase, Cochrane Library and Clinical trials.gov. Among 210 studies, five were included (two involving patients with a principal diagnosis of PD and three involving patients with bipolar disorder with comorbid PD or generalized anxiety disorder). All were eight-week trials and involved treatments with quetiapine extended release, risperidone and ziprasidone. Overall, a general lack of efficacy of SGAs on panic symptoms was observed. Some preliminary indications of the antipanic effectiveness of risperidone are insufficient to support its use in PD, primarily due to major limitations of the study. However, several methodological limitations may have negatively affected all of these studies, decreasing the validity of the results and making it difficult to draw reliable conclusions. Except for ziprasidone, SGAs were well tolerated in these short-term trials.